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2022 Administrative Forms

Claims

Coverage Determination Form

A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage plan.

Health Care Proxy Form

Complete this New York State document to legally appoint someone you trust, such as a family member or close friend, as your healthcare agent; to make healthcare decisions for you if you lose the ability to make decisions for yourself.

Medicare Advantage Request for Appeal

For use when appealing the denial of a service or claim. Appeal requests must be made within 60 calendar days of the denial notification.

Subscriber Claim Form

Medical benefits subscriber claim form

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How to submit a claim: 

Download and complete the claim form, then you have the option to mail in or submit online.

To submit online, sign into your member account and upload the form.

Pharmacy

Medicare Part-D Prescription Drug Claims Form

Complete this Medicare Part D Prescription Drug Claim Form to request reimbursement for Medicare Part D prescription drug benefits if you did not receive coverage at a pharmacy.

Drug Mail Order Form

Use this form for Home Delivery through Express Scripts

Request for Redetermination Part D Prescription Drug Denial

If Highmark Blue Cross Blue Shield of Western New York denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.

Vision

Out-of-Network Vision Services Claim Form

Use this form to request reimbursement for services received from providers who do not participate in the Davis Vision network.

Dental

2022 Medicare Advantage Dental Receipt Reimbursement

Acupuncture/Massage Therapy

2022 Medicare Advantage Acupuncture/Massage Therapy Receipt Reimbursement

Have questions about Medicare?

Highmark Blue Cross Blue Shield of Western New York Personal Medicare Advisors are here to help — every step of the way. 

Call us at 1-833-735-4511 (TTY 711).

October 1 - March 31, 8 a.m. to 8 p.m., 7 days a week
April 1 - September 30, 8 a.m. to 8 p.m., Monday - Friday

Medicare Questions?

We're here to help.

1-833-735-4511 (TTY 711)

Oct. 1 - Mar. 31, 8 a.m. - 8 p.m., 7 days a week
Apr. 1 - Sept. 30, 8 a.m. to 8 p.m., Monday - Friday

Highmark Blue Cross Blue Shield of Western New York (Highmark BCBSWNY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark BCBSWNY is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. Highmark BCBSWNY complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-833-735-4515 (TTY 711). 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-833-735-4515 (TTY 711).

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Content last updated: October 1, 2021